Antidepressant prescribing in Irish children: secular trends and international comparison in the context of a safety warning

BACKGROUND

In 2003, the Irish Medicines Board (IMB) warned against the treatment of childhood depression with selective serotonin reuptake inhibitors (SSRIs) due to increased risk of suicide. This study examined the effect of this warning on the prevalence of anti-depressants in Irish children and compared age and gender trends and international comparisons of prescription rates.

METHODS

A retrospective cohort study of the Irish Health Service Executive (HSE) pharmacy claims database for the General Medical Services (GMS) scheme for dispensed medication. Data were obtained for 2002-2011 for those aged ≤ 15 years. Prevalence of anti-depressants per 1000 eligible population, along with 95% confidence intervals, were calculated. A negative binomial regression analysis was used to investigate trends and compare rates across years, sex and age groups (0-4, 5-11, 12-15 years). International prescribing data were retrieved from the literature.

RESULTS

The prevalence of anti-depressants decreased from 4.74/1000 population (95% CI: 4.47-5.01) in 2002 to 2.61/1000 population (95% CI: 2.43-2.80) in 2008. SSRI rates decreased from 2002 to 2008. Prescription rates for contra-indicated SSRIs paroxetine, sertraline and citralopram decreased significantly from 2002 to 2005, and, apart from paroxetine, only small fluctuations were seen from 2005 onwards. Fluoxetine was the most frequently prescribed anti-depressant and rates increased between 2002 and 2011. Anti-depressant rates were higher for younger boys and older girls. The Irish prevalence was lower than the US, similar to the U.K. and higher than Germany and Denmark.

CONCLUSIONS

The direction and timing of these trends suggest that medical practitioners followed the IMB advice.

Benzodiazepine prescribing in children under 15 years of age receiving free medical care on the General Medical Services scheme in Ireland

OBJECTIVE

To examine the prevalence and secular trends in benzodiazepine (BZD) prescribing in the Irish paediatric population. In addition, we examine coprescribing of antiepileptic, antipsychotic, antidepressant and psychostimulants in children receiving BZD drugs and compare BZD prescribing in Ireland to that in other European countries.

SETTING

Data were obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive (HSE)--Primary Care Reimbursement Services (PCRS).

PARTICIPANTS

Children aged 0-15 years, on the HSE-PCRS database between January 2002 and December 2011, were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prescribing rates were reported over time (2002-2011) and duration (≤ or >90 days). Age (0-4, 5-11, 12-15) and gender trends were established. Rates of concomitant prescriptions for antiepileptic, antipsychotics, antidepressants and psychostimulants were reported. European prescribing data were retrieved from the literature.

RESULTS

Rates decreased from 2002 (8.56/1000 GMS population: 95% CI 8.20 to 8.92) to 2011 (5.33/1000 GMS population: 95% CI 5.10 to 5.55). Of those children currently receiving a BZD prescription, 6% were prescribed BZD for >90 days. Rates were higher for boys in the 0-4 and 5-11 age ranges, whereas for girls they were higher in the 12-15 age groups. A substantial proportion of children receiving BZD drugs are also prescribed antiepileptic (27%), antidepressant (11%), antipsychotic (5%) and psychostimulant (2%) medicines. Prescribing rates follow a similar pattern to that in other European countries.

CONCLUSIONS

While BZD prescribing trends have decreased in recent years, this study shows that a significant proportion of the GMS children population are being prescribed BZD in the long term. This study highlights the need for guidelines for BZD prescribing in children in terms of clinical indication and responsibility, coprescribing, dosage and duration of treatment.

Noninvasive magnetic resonance imaging of vessels affected by transplant arteriosclerosis in an experimental mouse aortic allograft model

BACKGROUND

Transplant arteriosclerosis is still the leading cause of late mortality after heart transplantation despite advances in immunosuppression regimes. Experimental mouse models have substantially contributed to a better understanding of the multifactorial pathogenesis, but the major limitation of these studies is the difficulty in monitoring progression of transplant arteriosclerosis over time. Therefore, the aim of this study was to investigate whether MR measurements are sensitive enough to detect characteristic vascular lesions in a small animal transplantation model.

METHODS

For this purpose we investigated 22 iso- and allogeneic aortic graft transplanted mice in vivo with a 4.7 T MR scanner using a 2D-RARE technique, 3D time-of-flight angiography and 3D phase contrast angiography as well as a special snake-based reconstruction algorithm. The MR lumen values of patency from native images and from 3D vessel reconstructions of the respective methods were correlated with conventional histological analysis.

RESULTS

A comparison of the different techniques showed that angiographic MR modalities correlated well with histological measurements. 2D-RARE sequences were inferior to the sequences obtained by other ones. Superior correlations and the most accurate results were found for vessel reconstruction based on 3D angiographic time-of-flight data.

CONCLUSION

These data demonstrate that mouse in vivo MR imaging is sensitive enough to detect and quantify vascular changes caused by transplant arteriosclerosis.

[Long-term analysis of disability pensions in survivors of the Holocaust: somatic and psychiatric diagnoses]

OBJECTIVE

Survivors of the Holocaust are known to suffer more often from mental as well as somatic consequential illness. The assessment of the degree of disability and invalidity due to the persecution complies with the interaction of directly Holocaust-related mental and somatic primary injuries as well as physical, psychical and psychosocial disadvantages and illnesses acquired later on.

METHODS

The presented descriptive as well as multivariate analyses included complete reports (expertise, medical records, physicians' assessments, witnessed hand-written notes of the patients) of 56 survivors of the Holocaust (36 women and 20 men).

RESULTS

The disability pension reports of 56 Holocaust survivors (36 women and 20 men) were analysed referring to the diagnostic groups and socio-demographic aspects. In 92.3 % a psychiatric illness could be diagnosed within the first year after liberation. In a separate analysis of somatic diagnoses, gastrointestinal diseases were statistically significant more often in Holocaust survivors with a degree of disability of more than 30 % (chi-square χ (2) = 4.0; df = 1; p = 0.046).

CONCLUSIONS

The question of an aggravation of psychiatrically relevant and persecution-associated symptomatology is mainly the objective of the expert opinion taking into account endogenous and exogenous factors such as so-called life events. Above all, newly acquired somatic diseases seem to be responsible for an aggravation of persecution-associated psychiatric symptoms, at least in the presented sample of Holocaust survivors.

Factors associated with deliberate self-harm among Irish adolescents

BACKGROUND

Deliberate self-harm (DSH) is a major public health problem, with young people most at risk. Lifetime prevalence of DSH in Irish adolescents is between 8% and 12%, and it is three times more prevalent among girls than boys. The aim of the study was to identify the psychological, life-style and life event factors associated with self-harm in Irish adolescents.

METHOD

A cross-sectional study was conducted, with 3881 adolescents in 39 schools completing an anonymous questionnaire as part of the Child and Adolescent Self-harm in Europe (CASE) study. There was an equal gender balance and 53.1% of students were 16 years old. Information was obtained on history of self-harm life events, and demographic, psychological and life-style factors.

RESULTS

Based on multivariate analyses, important factors associated with DSH among both genders were drug use and knowing a friend who had engaged in self-harm. Among girls, poor self-esteem, forced sexual activity, self-harm of a family member, fights with parents and problems with friendships also remained in the final model. For boys, experiencing bullying, problems with schoolwork, impulsivity and anxiety remained.

CONCLUSIONS

Distinct profiles of boys and girls who engage in self-harm were identified. Associations between DSH and some life-style and life event factors suggest that mental health factors are not the sole indicators of risk of self-harm. The importance of school-related risk factors underlines the need to develop gender-specific initiatives in schools to reduce the prevalence of self-harm.

Soluble amyloid precursor proteins in the cerebrospinal fluid as novel potential biomarkers of Alzheimer's disease: a multicenter study

In this report, we present the results of a multicenter study to test analytic and diagnostic performance of soluble forms of amyloid precursor proteins alpha and beta (sAPP alpha and sAPP beta) in the cerebrospinal fluid (CSF) of patients with different forms of dementing conditions. CSF samples were collected from 188 patients with early dementia (mini-mental state examination >or=20 in majority of cases) and mild cognitive impairment (MCI) in 12 gerontopsychiatric centers, and the clinical diagnoses were supported by neurochemical dementia diagnostic (NDD) tools: CSF amyloid beta peptides, Tau and phospho-Tau. sAPP alpha and sAPP beta were measured with multiplexing method based on electrochemiluminescence. sAPP alpha and sAPP beta CSF concentrations correlated with each other with very high correlation ratio (R=0.96, P<0.001). We observed highly significantly increased sAPP alpha and sAPP beta CSF concentrations in patients with NDD characteristic for Alzheimer's disease (AD) compared to those with NDD negative results. sAPP alpha and sAPP beta highly significantly separated patients with AD, whose diagnosis was supported by NDD findings (sAPP alpha: cutoff, 117.4 ng ml(-1), sensitivity, 68%, specificity, 85%, P<0.001; sAPP beta: cutoff, 181.8 ng ml(-1), sensitivity, 75%, specificity, 85%, P<0.001), from the patients clinically assessed as having other dementias and supported by NDD untypical for AD. We conclude sAPP alpha and sAPP beta might be regarded as novel promising biomarkers supporting the clinical diagnosis of AD.

[Pre-, peri- and postpartal depression]

INTRODUCTION

Postpartal affective disorders are with a prevalence between 8 % and 15 % highly frequent maternal diseases after childbirth. An undetected and untreated postpartum depression causes a wide range of negative consequences such as risk of a chronic manifestation of a major depression, social retreat, limitations in the bonding behavior, and behavioral disorders of the child. Therefore, an early detection of pregnant women at risk is warranted.

METHODS

Within a prospective study (FRAMES: Franconian Maternal Health Evaluation Studies), 1,100 pregnant women were interviewed with standardized questionnaires at three points of time: Prepartal (U1): from the 30 (th) week of pregnancy onwards, 48 - 72 hours (U2) postpartum (pp) und 6 - 8 months pp (U3). 554 women were included in the substudy Blue FRAMES, where an additional telephone interview at the 10 (th) day pp was conducted with a focus on symptoms relating to Baby Blues such as mood instability, irritability and concentration deficits. The Edinburgh Postnatal Depression Scale (EPDS) and the Hamilton Rating Scale For Depression (HAMD) were used for quantification of depressivity at each point of time.

RESULTS

EPDS values differed significantly (Friedman Test; chi (2) = 110.8; df = 2, p < 0,001) between the different examination points (Wilcoxon Test; U1 - U2: Z = -11.0; p < 0.001; U1 - U3: Z = -6.6; p < 0.001; U2 - U3: Z = -4,5; p < 0,001). Regarding EPDS values, higher values were observed prepartum (U1). After a decrease after two to three days postpartum (U2), values increased again. However, EPDS values six months postpartum (U3) were still lower than prepartum (U1).

DISCUSSION

The observed EPDS values postpartum are comparable to results of other studies. The higher EPDS values prepartum have a good predictive value. There is a great need and possibility for improved prevention of postpartal disorders, when appropriately addressed in the prepartum period.

Palliative first-line treatment with weekly high-dose 5-fluorouracil and sodium folinic acid (s-FA) (AIO-schedule) as 24h-infusion plus biweekly oxaliplatin (ox) in patients with definitively non-resectable metastatic colorectal cancer (CRC) following secondary (sec.) metastatic resection: An interdisciplinary phase II trial

e15073

Background: In an interdisciplinary phase II trial performed from 1995 to 1997 and based on a 5-FU monotherapy it was possible to achieve both a sec. metastatic resection after downsizing in 9 patients (17%) and a R0 resection offering curative option in 6 patients (11%) out of a total collective of 53 treated patients (Wein et al, Ann Oncol 2001). The objective of this phase II trial is to verify whether a combination therapy based on ox may improve the curative option in terms of a sec. metastatic resection in a patient cohort with identical inclusion - and exclusion criteria. Methods: Prospective evaluation of 50 patients.; palliative chemotherapy: ox (oxaliplatin, 85 mg/m2 i.v. as a 2h-infusion (inf.); d 1, 15, 29 qd 57) followed by 5-FU (2000 mg/m2 i.v. as a 24h- inf.; d 1, 8, 15, 22, 29, 36 qd 57) together with s-FA (Oncofolic, 500 mg/m2 i.v. as a 24h-inf.; d 1, 8, 15, 22, 29, 36 qd 57) via a miniature pump system. Results: Last date of evaluation: Sep/30/2008; median age: 63 years; chemoth. appl.: total number: 935; higher grade toxicity (grade 3+4): diarrhea 20,0 %, nausea 4,0 %; vomitus 6,0 %; hand-foot-syndrome 2,0 %; fever/infection 2,0 %; response: CR: 2,0 %; PR: 52,0 %; SD: 32,0 %; PD: 12,0 %; not evaluable: 2,0 %; tumor control (CR, PR, SD): 86,0 %; sec. metastatic resection: R0: 28,0 %; R1: 2,0 %; R2 8,0 %; TTP (n = 50): 9,8 months. Conclusion: Combination chemotherapy with weekly 5-FU and s-FA (AIO) plus bi-weekly ox on an outpatient basis is an effective palliative treatment schedule offering a high rate of curative metastatic resection with solely low grade toxicity and no higher grade neurotoxic side effects. Final results in terms of median survival remain to be seen whereas they are certainly influenced by the second line therapy.

No significant financial relationships to disclose.

Palliative systemic chemotherapy with gemcitabine (GEM) and 5-fluorouracil (5-FU) as 24h-infusion in patients with advanced inoperable biliary tract cancer (UICC stage IV)

e15633

Background: Due to the late diagnosis of biliary tract carcinomas in an advanced tumor stage, the application of palliative chemotherapy frequently remains as a possible treatment option. The aim of this study is to evaluate the efficacy and toxic side effects of a chemotherapy schedule consisting of GEM combined with 5-FU in patients (pts.) with metastatic biliary tract cancer. Methods: Evaluation of 35 pts. based on our prospective tumor registry data; essential inclusion criteria: histologically proven adeno-carcinoma, UICC stage IV, chemonaivity; all the pts. were presented in the interdisciplinary tumorboard of Erlangen University and were primarily non-curatively-resectable (n = 35); evaluation period: 11/1998 - 09/2008; treatment schedule: 1.000 mg/m2 of GEM as a 0.5h-infusion (inf.) combined with 2.000 mg/m2 of 5-FU as a 24h-inf. via port catheter on day 1, 8, 15 qd 22. Results: Median age: 64 years; men/women: n=18/17; ECOG 0/1/2: n=10/21/4; localisation: intrahepatic bile ducts: n=19, extrahepatic bile ducts: n=11; gall bladder: n=4; metastases: liver: 91.4%, lymph nodes: 51.4%, peritoneum: 28.8%, bones: 8.6%, intestine: 8.6%, skin: 2.9%, lungs: 2.9%; chemotherapy applications: total number: 486, average value/patient: 13.9; CA 19–9 elevated yes/no: n=13/22 (37.1%/62.9%); CEA elevated yes/no: n=15/9 (42.9%/25.7%, not evaluable: 11); higher grade toxicity (III or IV): leukocytopenia III: 14.3%, thrombocytopenia III: 2.9%, weariness III: 2.9%, diarrhea III: 5.7%, diarrhea IV: 2.9%, vomiting IV: 2.9%, pain III: 5.7%, ascites III: 5.7%, infections III: 2.9%, thromboembolia IV: 2.9%, elevated bilirubin value III: 1.7%, grade IV: 8.3%; deep leg vein thrombosis: 15%; median TTP: 5.1 months (95% CI: 2.9 - 7.2); median overall survival: 10.4 months (95% CI: 7.9 - 12.9); 6-months-/1-year-/2-year-survival rate: 65.7%/45.7%/17.1%; response rate: PR: n=5 (14.3%), SD: n=18 (51.4%), PD: n=7 (20%), not evaluable: n=5 (14.3%); tumor control (PR/SD): n=23 (65.7%); median follow-up: 10.4 months. Conclusions: Combination chemotherapy with weekly GEM as a 0.5h-inf. and 5-FU as a 24h-inf. on an out-patient basis is an effective palliative treatment schedule with solely low grade toxicity.

No significant financial relationships to disclose.

Herp mRNA expression in patients classified according to Lesch's typology

Chronic alcoholism is associated with hyperhomocysteinemia. Herp (homocysteine-induced endoplasmic reticulum [ER] protein) levels are elevated as a response to ER stress prior to mitochondrial dysfunction and cell death. The Lesch classification system has been applied in many studies and has been found useful. This study was undertaken to assess Herp mRNA expression in actively drinking patients with alcoholism who were classified according to Lesch's typology. Herp mRNA expression levels were measured by quantitative PCR in the blood of 76 male alcoholic patients. Patients were classified according to Lesch's typology (type I-IV). With respect to Lesch's typology, a significant difference in Herp mRNA expression regarding the four subtypes could be shown (F[3,72]=2.83, P=.044). In a logistic regression model (dependent variable Herp dichotomized by a median-split; adjusted for age and homocysteine levels) the subtype II differed statistically significant from the others (odds ratio, 5.75; 95% confidence interval, 2.07-15.98; P=.001). Type II alcoholic patients had a statistically significant higher expression of Herp mRNA due to upregulation of the expression of this neuroprotective cell non-chaperone by toxic effects of ethanol. These findings might explain why type II patients do not express severe withdrawal symptomatology (i.e., withdrawal seizures). These findings may be useful in the understanding and treatment considerations of different subtypes of alcohol dependence.

Ghrelin and eating disturbances in psychiatric disorders

INTRODUCTION

Appetite and eating behavior are frequently altered in psychiatric patients. The newly discovered gut-derived neuropeptide ghrelin simulates hunger and weight gain. Therefore, it might be involved in appetite regulation during psychiatric disorders.

METHODS

In 83 depressed, 42 schizophrenic patients and 46 healthy controls plasma ghrelin levels were measured, and the psychometric scores on the Three-Factor Eating Questionnaire (TFEQ) were assessed.

RESULTS

Neither ghrelin levels nor TFEQ scores differed between both patient groups and healthy subjects. However, TFEQ subscale 2 (disinhibition) was predicted by BMI-corrected ghrelin levels, while age, sex, smoking, and medication did not show any influence.

DISCUSSION

Ghrelin correlates with factors of eating behavior, specifically with subscale 2 on the TFEQ. Ghrelin might be involved in appetite-regulating pathways during psychiatric disorders. However, its influence is not likely to be displayed as a difference between diagnostic groups. Rather, ghrelin is associated with eating behavior in psychiatric patients meaning susceptibility to eating problems.

Dopamine and N-methyl-D-aspartate receptor expression in peripheral blood of patients undergoing alcohol withdrawal

The aim of the present pilot study was to explore whether a change in cerebral receptors can be demonstrated in human peripheral blood lymphocytes during alcohol withdrawal. Dopamine (D1 and D2) and NMDA (1 and 2B) receptor expressions of 14 male patients suffering from alcohol-dependency were assessed through quantitative RT-PCR. A significant difference in D1 receptor expression (T = 2.361; p = 0.035) in terms of up-regulation could be shown, though there were no significant changes concerning D2, NMDA1 or NMDA2B receptor expression.

Vitamin deficiency and hyperhomocysteinemia in pseudoexfoliation glaucoma

Pseudoexfoliation syndrome (PEX) is a systemic disorder characterized by the deposition of an abnormal fibrillar material in ocular and various extraocular tissues. It represents the most common identifiable cause of glaucoma (PEX glaucoma = PEXG). Due to similar pathogenetic mechanisms, glaucoma has been called "ocular Alzheimer's disease". PEXG and Alzheimer's disease share common associations such as the higher prevalence of hyperhomocysteinemia in both disorders. In order to investigate the cause of hyperhomocysteinemia in PEXG, we evaluated B-vitamin levels (folate, B12, B6) and their associations with homocysteine (Hcy) in plasma of 70 PEXG patients and 70 control subjects. Folate, vitamin B12 and B6 levels were significantly decreased and associated with elevated Hcy levels in PEXG. Low B-vitamin levels in PEX might also help explain, at least in part, the higher prevalence of B-vitamin deficiency in disorders associated with PEX such as Alzhemier's disease.

[Time-multiplexing stereophotography: 2D and 3D qualitative and semiquantitative evaluation of glaucomatous optic disc atrophy]

PURPOSE

Real color documentation of the optic nerve head (ONH) is one of the most important methods in identifying early progression of glaucomatous optic nerve damage. This study qualitatively and semiquantitatively compared the evaluation of ONH photographs, using a 3D time-multiplexing system and conventional 2D photography, visualized on a computer monitor.

PATIENTS AND METHODS

Twelve 15 degrees sequential stereophotographs from the Erlangen Glaucoma Registry were scanned by a SprintScan 35 Plus Film scanner (Polaroid, Waltham, MA, USA) and converted by computer software (3D-PIX, NuVision, McNaughton Inc., Beaverton, OR, USA) in jps format (3D). The same ONH images were shown in 2D and 3D to 22 subjects: 12 residents and ten ophthalmologists and evaluated using a standardized questionnaire.

RESULTS

We observed a significantly better evaluation with stereoscopic pictures for both qualitative parameters (cup depth, visibility of the retinal nerve fibers, and the thinnest location of the neuroretinal rim) and quantitative parameters (c/d ratio and size of the disc, depending on the training level: in 3D better evaluation by the residents, in 2D by the ophthalmologists). With 2D pictures, we found better evaluation of the B zone and the stage of atrophy. Other than the method used for the entire evaluation, there was no significant difference between the groups. For the parameters weighed for clinical importance, the score of correct answers was significantly better with stereoscopic pictures.

CONCLUSION

This study showed a significantly better evaluation of glaucomatous ONH atrophy with 3D images than with 2D pictures, independently of the evaluators' clinical training level. The computer-based evaluation of ONH atrophy using a time-multiplexing system (shutter glasses) may improve the diagnosis of glaucoma patients.

Homocysteine levels in aqueous humor and plasma of patients with primary open-angle glaucoma

We determined homocysteine (Hcy) levels in aqueous humor (AH) and plasma and their association with B-vitamin levels in patients with primary open-angle glaucoma (POAG) and controls. Both AH Hcy and plasma Hcy levels were significantly increased in POAG, and elevation of AH Hcy and plasma Hcy was a significant risk factor for POAG. In contrast to controls, neither plasma nor AH Hcy of POAG patients demonstrated a significant association with important non-genetic determinants of elevated Hcy such as low B-vitamin levels, increasing age and caffeine consumption. Considering that Hcy is a neurotoxin that induces apoptotic retinal ganglion cell death via stimulation of the N-methyl-D-asparate (NMDA) receptor, increased Hcy concentrations in AH and plasma might contribute to the optic nerve damage in POAG.

Increased frequency of cardioembolism and patent foramen ovale in patients with stroke and a positive travel history suggesting economy class stroke syndrome

OBJECTIVE

To investigate the frequency of acute stroke in patients with a recent travel history and to analyse risk factors, stroke patterns and presence of a patent foramen ovale (PFO) in this patient group.

DESIGN

One-year prospective observational study.

SETTING

Single-centre study.

METHODS

Enrolling all patients presenting with a first cerebral ischaemia and complementing the usual history with a standardised travel history.

RESULTS

Of 338 patients with acute stroke, 42 had a positive travel history (PTH) (12.4%). Patients with a PTH were significantly younger (56.6 (SD 13) years) than patients (66.9 (13.2) years, p = 0.0001) with a negative travel history (NTH). Frequency of PFO in the PTH group (13; 44.8%) was significantly higher than in the NTH group (7; 10.8%) (p = 0.0001), even after patients were dichotomised into two age groups (younger and older than median of all

PATIENTS

31% v 6.1%, p = 0.007 and 13.8% v 4.6%, p = 0.022, respectively). PTH patients had fewer stroke risk factors (2.2 (1.4) v 3.3 (1.6), p = 0.0001) and a different risk profile with a lower frequency of diabetes (11.9% v 31.4%, p = 0.009), hypertension (52.4% v 78.7%, p = 0.0001), atrial fibrillation (7.1% v 22%, p = 0.025) and others (16.7% v 38.9%, p = 0.005). In contrast, PTH patients had significantly more cardioembolic (35.7% v 19.3%, p = 0.023) and cryptogenic strokes (50% v 19.9%, p = 0.0001) and more often ischaemia in the territory of the posterior cerebral artery (29.6% v 6.3%, p = 0.0001).

CONCLUSIONS

The finding that more PTH patients had a PFO and a cardioembolic stroke pattern but that fewer had other typical stroke risk factors led to the hypothesis that PFO is a risk factor for economy class stroke syndrome.

Short-term cognition deficits during early alcohol withdrawal are associated with elevated plasma homocysteine levels in patients with alcoholism

Higher plasma homocysteine levels have been found in actively drinking alcoholics as well as in early abstinent patients. Furthermore, elevated homocysteine levels are associated with cognitive decline in dementia and in healthy elderly people. The aim of this prospective study was to investigate a possible association between homocysteine serum levels and clinically well known cognitive deficits during alcohol withdrawal. We examined 89 patients (67 men, 22 women) during early withdrawal treatment. Cognitive function was assessed using the c.I.-Test. Patients with cognitive deficits showed significantly higher homocysteine serum levels (Mann-Whitney-U, p=0.004) than patients without cognitive deficits, while the difference in blood alcohol concentration was not significant. Using logistic regression analysis, cognitive deficits were best predicted by high homocysteine serum levels (Wald chi2=4.071, OR=1.043, 95% CI 1.001-1.086, p<0.05), which was confirmed by Receiver Operating Curves (AUC=0.68, 95% CI=0.57-0.79, p=0.004). The present results show first evidence of an association between elevated plasma homocysteine levels in alcoholics and cognition deficits in patients undergoing alcohol withdrawal.

Terminal deoxynucleotidyl transferase-positive cells in trephine biopsies following bone marrow or peripheral stem cell transplantation reflect vigorous B-cell generation

AIMS

Bone marrow is the major site of B-cell generation in humans. While in early childhood a high number of B-cell precursors is found in the bone marrow, only very few such cells are usually detectable in adult bone marrow. To assess the number of immature B cells present after haematopoietic cell transplantation the number of terminal deoxynucleotidyl transferase (TdT)-positive cells in regenerating bone marrow of adult patients was analysed.

METHODS AND RESULTS

Bone marrow biopsy specimens were analysed from patients after allogeneic bone marrow transplantation (BMT; n = 14) or stem cell transplantation (SCT; n = 25) and autologous BMT (n = 9). Specimens from 11 untransplanted adult patients and 11 infants were also studied, as negative and positive controls, respectively. Immunohistochemistry was performed on paraffin-embedded bone marrow biopsy sections using TdT as a marker of lymphoid progenitors. Immunoreactivity for CD79a, CD20 and CD10 was used to confirm their B-cell origin. Using computer-assisted automated image analysis we quantitatively assessed the TdT+ cells present. We found a significant increase in the numbers of B-cell precursors in the bone marrow after allogeneic and autologous BMT/SCT compared with adult controls (P = 0.022). To analyse this in detail, we followed some patients after allogeneic BMT/SCT for up to 1445 days, when a marked B-cell increase was still detectable. However, the median number of TdT+ B cells after BMT/SCT was significantly lower than the number of equivalent B cells in infantile bone marrow biopsy specimens (P < 0.001).

CONCLUSIONS

Bone marrow of adult patients after BMT/SCT is capable of initiating vigorous precursor B-cell generation, which is not seen in untransplanted adults. However, the increase of immature B cells was variable in our study. Only in two young adult patients did it reach the magnitude of B-cell generation seen in infantile bone marrow where immunocompetent B cells are produced normally. A marked increase in number of immature B cells post-transplant may mimic B-cell acute lymphoblastic leukaemia (B-ALL). This is a potential problem in patients transplanted for B-ALL itself. Since reactive and neoplastic B-cell precursors share the same immunophenotype in paraffin-embedded tissue, additional tools, particularly molecular techniques, may have to be employed to establish the correct diagnosis.

Homocysteine associated genomic DNA hypermethylation in patients with chronic alcoholism

Higher plasma homocysteine concentrations can influence genomic DNA methylation in peripheral blood cells. In the present controlled study we observed a significant increase (10%) of genomic DNA methylation in patients with alcoholism (t = -3.16, df = 158, p = 0.002) which was significantly associated with their elevated homocysteine levels (multiple linear regression, p < 0.001). Since methylation of DNA is an important epigenetic factor in regulation of gene expression these findings may have important implications for a possible subsequent derangement of epigenetic control these patients.

Joint analysis of the NACP-REP1 marker within the alpha synuclein gene concludes association with alcohol dependence

Various studies have linked alcohol dependence phenotypes to chromosome 4. One candidate gene is NACP (non-amyloid component of plaques), coding for alpha synuclein. Recently, it has been shown that alpha synuclein mRNA is increased in alcohol-dependent patients within withdrawal state. This increase is significantly associated with craving, especially obsessive craving. On the basis of these observations, the present study analysed two polymorphic repeats within the NACP gene. We found highly significant longer alleles of NACP-REP1 in alcohol-dependent patients compared with healthy controls (Kruskal-Wallis test, chi(2)=99.5; df=3, P<0.001). In addition, these lengths significantly correlate with levels of expressed alpha synuclein mRNA (chi(2)=8.83; df=2, P=0.012). The present results point to a novel approach for a genetic determination of craving, a key factor in the genesis and maintenance not only of alcoholism but also of addiction in general.